Challenges and Opportunities to Address Aggressive Coding Practices by Medicare Advantage Plans
Authors: Nancy L. Keating
Journal: Annals of Internal Medicine (2023)

Ideas and Opinions6 June 2023Challenges and Opportunities to Address Aggressive Coding Practices by Medicare Advantage PlansNancy L. Keating, MD, MPHNancy L. Keating, MD, MPHDepartment of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts (N.L.K.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-0534 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In December 2022, I saw Ms. G, a patient in her late 60s with well-controlled hypertension, obesity (body mass index, 37 kg/m2), hyperlipidemia (receiving statin therapy), and spinal stenosis (without recent pain). Her hemoglobin A1c level was 5.5% in November 2019 and 5.3% at our visit. She mentioned that someone from her insurance company (a Medicare Advantage plan) had visited her home recently. I received a letter 1 week later, noting that an advanced practice clinician visited my patient’s home. It reported a point-of-care hemoglobin A1c level of 5.8% and a body mass index of 37.76 kg/m2. The letter suggested ...References1. Kronick R, Welch WP. Measuring coding intensity in the Medicare Advantage program. Medicare & Medicaid Res Rev. 2014;4. doi:10.5600/mmrr.2014.004.02.a06 CrossrefMedlineGoogle Scholar2. Geruso M, Layton T. Upcoding: evidence from Medicare on squishy risk adjustment. J Polit Econ. 2020;12:984-1026. [PMID: 32719571] doi:10.1086/704756 CrossrefMedlineGoogle Scholar3. Meyers DJ, Trivedi AN. Medicare Advantage chart reviews are associated with billions in additional payments for some plans. Med Care. 2021;59:96-100. [PMID: 32925467] doi:10.1097/MLR.0000000000001412 CrossrefMedlineGoogle Scholar4. U.S. Department of Health and Human Services Office of Inspector General. Billions in estimated Medicare Advantage payments from chart reviews raise concerns. December 2019. OEI-03-17-00470. Accessed at https://oig.hhs.gov/oei/reports/oei-03-17-00470.pdf on 1 February 2023. Google Scholar5. Medicare Payment Advisory Commission Meeting. The Medicare Advantage program: Status report. Presentation to commissioners at 1:15 pm on January 12 2023. Accessed at www.medpac.gov/wp-content/uploads/2023/01/MedPAC-MA-status-report-Jan-2023.pdf on 1 February 2023. Google Scholar6. Medicare Payment Advisory Commission. Report to the Congress: Medicare Payment Policy 2016. Chapter 12: The Medicare Advantage program: Status report and mandated report on dual eligible special needs plans. Accessed at www.medpac.gov/wp-content/uploads/2022/03/Mar22_MedPAC_ReportToCongress_Ch12_SEC.pdf on 14 April 2023. Google Scholar7. Centers for Medicare & Medicaid Services. Medicare Advantage risk adjustment data validation final rule (CMS-4185-F2) fact sheet. January 30, 2023. Accessed at www.cms.gov/newsroom/fact-sheets/medicare-advantage-risk-adjustment-data-validation-final-rule-cms-4185-f2-fact-sheet on 1 February 2023. Google Scholar8. Centers for Medicare and Medicaid Services. Reporting Fraud. Accessed at www.cms.gov/About-CMS/Components/CPI/CPIReportingFraud on 1 February 2023. Google Scholar9. Centers for Medicare and Medicaid Services. Announcement of Calendar Year (CY) 2024 Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. March 31, 2023. Accessed at https://www.cms.gov/files/document/2024-announcement-pdf on 14 April 2023. Google Scholar10. Landon BE, Mechanic RE. The paradox of coding — policy concerns raised by risk-based provider contracts. N Engl J Med. 2017;13:2011-2013. [PMID: 28953441] doi:10.1056/NEJMp1708084 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAuthors: Nancy L. Keating, MD, MPHAffiliations: Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts (N.L.K.).Acknowledgment: The author thanks Bruce E. Landon, MD, MBA, and J. Michael McWilliams, MD, PhD, for helpful comments on an earlier version of the manuscript.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0534.Corresponding Author: Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115; e-mail, keating@hcp.med.harvard.edu.Author Contributions: Conception and design: N.L. Keating.Analysis and interpretation of the data: N.L. Keating.Drafting of the article: N.L. Keating.Critical revision for important intellectual content: N.L. Keating.Final approval of the article: N.L. Keating.Administrative, technical, or logistic support: N.L. Keating.Collection and assembly of data: N.L. Keating.This article was published at Annals.org on 6 June 2023. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics July 2023Volume 176, Issue 7Page: 987-988KeywordsDiagnostic techniquesElectronic medical recordsHealth careMedicareRisk adjustmentsRisk assessments ePublished: 6 June 2023 Issue Published: July 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...